The Case of the Cyanotic Hands

I went in to see a patient whose hands suddenly turned blue at work. She stated that she couldn’t feel any of her fingertips once they started turning blue and said that she was “cleaning” before the symptoms occurred.

As I walked into the room, all of the fingers on both her hands were definitely dusky appearing. Her upper arms appeared OK. Her lips weren’t cyanotic.

So I sat there taking a history thinking to myself what the hell could be causing this.

Raynauds doesn’t affect the whole hand like that.
Sudden onset of a cyanotic heart lesion wasn’t very likely.
She wasn’t working in the cold, and she was cleaning toilets with a scrub brush, so she didn’t have an exposure to some kind of industrial solvent.
She didn’t have pain, so it wasn’t like she had bilateral arterial occlusions or some other vascular problem.
She wasn’t taking any medications. Was she poisoned?

I was clueless.

I went to examine her. Her hands were warm. She had good pulses. She had normal capillary refill. Good pain sensation with a toothpick. Then I noticed that there was no blue between her fingers, only on front and back of her hands up to her wrist.

Wait a minute.

I grabbed a washcloth, wet it, and scrubbed the back of her hand. The washcloth turned blue and her hand turned pink.

The girl’s mother did a facepalm. “We waited 2 hours to have someone wash your hands?”

“Well, the toilets did have those blue drop-in tablets in them,” the patient mumbled.

So I set them up for discharge and told them “at least there’s nothing serious – right?”
When the nurse went in with their papers, they were all upset because I didn’t do anything to diagnose why the patient’s fingers were tingling.

Um … its probably from the blue dye. See your doctor in a few days if it isn’t better. He can set you up for a neurology appointment and a nerve conduction study if necessary.

When the secretary read the discharge diagnosis, she loudly said “that’s just gross.”

“Why?” I asked.

I saw that girl go to the bathroom twice while she was here and if you got that dye off with a washcloth and water, there was no way in heck that she washed her hands in that bathroom.”

I put my drink down and went to wash my hands again after having touched the patient’s hands … just in case.

11 Responses to “The Case of the Cyanotic Hands”

This actually sort of happened to me. I was wearing new jeans and the blue on them rubbed off onto my hands. I was sitting with my mom when she noticed and she freaked out. I got a little worried at first because I have a bit of a heart condition, but I *felt* fine. I looked closer and I could see the blue was darker in the creases of my skin, which made me suspicious. A quick hand wash a few minutes later, and I was cured!

My mother (a pediatrician) had a similar case. Actually a FP doc saw the kid first and was going to order a bunch of tests. My mom was smart enough to see the kid was wearing blue jeans and was using an aloe lotion for poison ivy. Turned out the alcohol in the lotion was making the dye run. She came in and saved the patient from having to have lots of tests.

Anyway, the first patient I saw during my shift yesterday was a little old lady who came in with blood clots and blisters on her fingers when she woke up yesterday morning. She was on Coumadin and was worried that she was throwing clots over her body. She had herself so worked up that she was close to crying when I walked in the room. As I walked through the door she stood up from the bed and walked toward me with her hands extended to show me. I tried to calm her down a little so I could get a history from her.

She had changed her dose of Coumadin earlier in the week. The level was too high so her dose was decreased. She went out shopping the day before and may have been carrying some bags that may have pinched her fingers. Maybe her level was too high. All she knows is that she woke up with these tender areas on her fingertips. They were discolored anywhere from dark red to purple.
When I looked at her hands, the marks weren’t blisters and they were oddly colored. Not the dark magenta hue of blood, but almost a pinkish color with some purple areas mixed in. She had also apparently taken a magic marker and drawn lines under a couple of the marks with a black Sharpie pen. I asked her why she had done so.

“I didn’t draw under them, doctor.”
“It sure looks like ink to me.”

I got a washcloth, put some soap and water on it and began rubbing. Not only did the ink disappear, but so did the blood clots.

This is the priceless part about being a doctor. Within fifteen seconds I made some poor lady go from crying tears of fear to crying tears of laughter.

“Oh my goodness. I just remembered,” she said, “I changed the ink cartridges on my printer last night before I went to bed.”

She got this silly grin, gave me this big hug and a wet lipstick kiss, and rushed out to the waiting room to tell her husband. I couldn’t hear what she was saying, but her voice was raised and she was talking fast like she had a few too many drinks at a dinner party. Soon I heard several people in the waiting room laughing along with her.

An ink cartridge, a washcloth and some soap. Now we both have a good story to tell.